Ethnic differences in invasive management of coronary disease: prospective cohort study of patients undergoing angiography

Abstract

Objectives: To compare rates of revascularisation in south Asian and white patients undergoing coronary angiography in relation to the appropriateness of revascularisation and clinical outcome.

Design: Prospective cohort study of patients with two and a half years' follow up; appropriateness of revascularisation rated by nine experts with no knowledge of ethnicity of patient.

Setting: Tertiary cardiac centre in London with referral from five contiguous health authorities.

Participants: Consecutive patients (502 south Asian, 2974 white) undergoing coronary angiography in the appropriateness of coronary revascularisation study (ACRE).

Main outcome measures: Coronary revascularisation, non-fatal myocardial infarction, mortality.

Results: There was no difference between south Asian and white patients in the proportions deemed appropriate for revascularisation (72% (361) v 68% (2022)) or in the proportions for whom the physician's intended management was revascularisation (39% (196) v 41% (1218)). Among patients appropriate for revascularisation, age adjusted rates of coronary angioplasty (hazard ratio 0.69, 95% confidence interval 0.47 to 1.00, P=0.058) and coronary artery bypass grafting (0.74, 0.58 to 0.91, P=0.007) were lower in south Asian than in white patients. These differences were smaller but still present after adjustment for socioeconomic status and after restriction of analysis to those patients for whom the intended management was revascularisation. There were no differences in mortality and non-fatal myocardial infarction between south Asian and white patients (1.07, 0.78 to 1.47).

Conclusion: Among patients deemed appropriate for coronary artery bypass grafting, south Asian patients are less likely than white patients to receive it. This difference is not explained by physician bias.

Figure 1

Probability of any revascularisation in south Asian and white patients after angiography among all patients

Figure 2

Probability of south Asian and white patients receiving coronary angioplasty after angiography among those deemed appropriate for angioplasty

Figure 3

Probability of south Asian and white patients receiving coronary artery bypass graft after angiography among those deemed appropriate for coronary artery bypass graft

Figure 4

Age adjusted hazard ratios for death and non-fatal myocardial infarction at 2.5 year follow up for south Asian with white patients